1. Field of the Invention
A system and method of evaluating medical service providers, and before or after an initial medical service provider visit by a claimant, determining whether to direct that claimant on subsequent medical service provider visits to a different medical service provider to optimize efficiency of care and minimize cost at the claim level.
2. Description of the Prior Art
Insurance companies, organizations, and businesses constantly strive to manage health care costs while maintaining or improving patient care. These health care costs include the costs of claims associated with group health, individual health, and property & casualty insurance. In view of increasing health care costs and increasing percentages of a business's or organization's revenue these costs represent, insurance companies, businesses, and organizations are taking steps to introduce new methods of managing claims and reducing costs. One such method includes storing a medical service provider list on a database wherein each medical service provider has at least one provider profile including general provider information. The method may also include storing a claim list including all claimants and claims made by claimants with all of the medical service providers on the provider list. Claim profiles are developed for each claim on the claim list including general provider information and general claimant information.
Prior methods may also assign a provider score for each of the provider profiles based on the claim profiles. These methods may also rank the plurality of medical service providers by the provider scores in that they group the medical service providers achieving provider scores above a fixed rank value into a first provider group and groups the medical service providers achieving provider scores below a fixed rank value into a second provider group. Prior-art medical service provider groups are often tied to provider networks.
Insurance companies, organizations, and businesses typically use provider networks to control medical service costs. In a provider network of medical service providers, fixed rates or standardized discounts apply to given types of medical service. However, provider networks do not limit the number of medical procedures performed for a given claimant during a given claim (utilization), and overall claim costs can be quite steep. A discount or fixed medical service rate as used in a provider network does not truly lead to optimized medical costs at the claim level if utilization is not controlled. Currently, the prior art methods of provider evaluation are limited in their ability to improve efficiency and reduce costs.
In view of the above issues, a method and system is needed to transform the processing of claimants. Without the additional step of directing certain types of claimants to specific medical service providers, not provider networks, the success of directing claimants cannot be effectively measured and used to redefine medical service provider groups and claimant groups in order to improve efficiency and optimize medical costs at the claim level.